Solid bone tumors of the spine : Diagnostic performance of apparent diffusion coefficient measured using diffusion-weighted MRI using histology as a reference standard

Purpose To assess the diagnostic performance of mean apparent diffusion coefficient (mADC) in differentiating benign from malignant bone spine tumors, using histology as a reference standard. Conventional magnetic resonance imaging (MRI) sequences have good reliability in evaluating spinal bone tumors, although some features of benign and malignant cancers may overlap, making the differential diagnosis challenging. Materials and Methods In all, 116 patients (62 males, 54 females; mean age 59.5\u2009\ub1\u200914.1) with biopsy-proven spinal bone tumors were studied. Field strength/sequences: 1.5T MR system; T1-weighted turbo spin-echo (repetition time / echo time [TR/TE], 500/13 msec; number of excitations [NEX], 2; slice thickness, 4\u2009mm), T2-weighted turbo spin-echo (TR/TE, 4100/102 msec; NEX, 2; slice thickness, 4\u2009mm), short tau inversion recovery (TR/TE, 4800/89 msec; NEX, 2; slice thickness, 4\u2009mm, IT, 140 msec), axial spin-echo echo-planar diffusion-weighted imaging (DWI) (TR/TE 5200/72 msec; slice thickness 5\u2009mm; field of view, 300; interslice gap, 1.5\u2009mm; NEX, 6; echo-planar imaging factor, 96; no parallel imaging) with b-values of 0 and 1000 s/mm\ub2, and 3D fat-suppressed T1-weighted gradient-recalled-echo (TR/TE, 500/13 msec; slice thickness, 4\u2009mm) after administration of 0.2\u2009ml/kg body weight gadolinum-diethylenetriamine pentaacetic acid. Two readers manually drew regions of interest on the solid portion of the lesion (hyperintense on T2-weighted images, hypointense on T1-weighted images, and enhanced after gadolinium administration on fat-suppressed T1-weighted images) to calculate mADC. Histology was used as the reference standard. Tumors were classified into malignant primary tumors (MPT), bone metastases (BM), or benign primary tumors (BPT). Statistical tests: Nonnormality of distribution was tested with the Shapiro\u2013Wilk test. The Kruskal\u2013Wallis and Mann\u2013Whitney U-test with Bonferroni correction were used. Sensitivity and specificity of the mADC values for BM, MPT, and BPT were calculated. Approximate receiver operating characteristic curves were created. Interobserver reproducibility was evaluated using the intraclass correlation coefficient (ICC). Results The mADC values of MPT (n\u2009=\u200935), BM (n\u2009=\u200965), and BPT (n\u2009=\u200916) were 1.00\u2009\ub1\u20090.32 (0.59\u20132.10) 7 10 123 mm2/s, 1.02\u2009\ub1\u20090.25 (0.73\u20131.96) 7 10 123 mm2/s, 1.31\u2009\ub1\u20090.36 (0.83\u20132.14) 7 10 123 mm2/s, respectively. The mADC was significantly different between BPT and all malignant lesions (BM+MPT) (P < 0.001), BM and BPT (P\u2009=\u20090.008), and MPT and BPT (P\u2009=\u20090.008). No difference was found between BM and MPT (P\u2009=\u20090.999). An mADC threshold of 0.952 7 10 123 mm2/s yielded 81.3% sensitivity, 55.0% specificity. Accuracy was 76% (95% confidence interval [CI]\u2009=\u200963.9%\u201388.1%). Interobserver reproducibility was almost perfect (ICC\u2009=\u20090.916; 95% CI\u2009=\u20090.879\u20130.942). Conclusion DWI with mADC quantification is a reproducible tool to differentiate benign from malignant solid tumors with 76% accuracy. The mADC values of BPT were statistically higher than that of malignant tumors. However, the large overlap between cases may make mADC not helpful in a specific patient. Level of Evidence: 3 Technical Efficacy: Stage

Increased diagnostic yield of small bowel tumors with PillCam: the role of capsule endoscopy in the diagnosis and treatment of gastrointestinal stromal tumors (GISTs). Italian single-center experience.

Background. Gastrointestinal stromal tumors (GISTs) are rare tumors, accounting for 1-3% of all gastrointestinal malignancies; they are, however, the most common gastric and small bowel mesenchymal tumors. The length and relative inaccessibility of the small bowel have long constrained the diagnosis of GISTs mainly presenting with chronic or intermittent bleeding as the sole clinical manifestation. Aim. To report on the prevalence of small bowel GISTs in a prospectively recorded series of patients undergoing capsule endoscopy (CE). Patients and methods. Between 2001 and 2007 five hundred patients were referred to our endoscopy unit for small bowel evaluation with capsule endoscopy. We retrospectively evaluated all charts. The main indications for CE were obscure-occult or obscure-overt bleeding. Two hundred eighty-nine patients underwent CE for either obscure-occult or obscure-overt bleeding and 211 for other indications. Patient outcome and care processes were measured by follow-up telephone interviews and chart review. Statistical computations were performed using Fisher\u2019s exact test and Student\u2019s t-test. Results. CE identified a small bowel tumor in 20 patients (4.0%) and 9 tumors turned out to be GISTs (45.0%). Traditional endoscopic and radiological imaging failed to detect the GIST in all these cases. In one case a small bowel GIST was diagnosed by angiography and CE proved false negative. Overall, CE was able to diagnose a small bowel GIST in 9 out of 10 cases. All patients underwent surgical treatment and showed normalized hemoglobin levels at follow-up. The main limitation of this study is the small number of cases. Conclusions. CE is an effective and sensitive diagnostic device compared with conventional radiology and plays an important role in the algorithm for the diagnostic work-up of suspected small bowel tumors

The sacral chordoma margin

Objective: Aim of the manuscript is to discuss how to improve margins in sacral chordoma. Background: Chordoma is a rare neoplasm, arising in half cases from the sacrum, with reported local failure in &gt;50% after surgery. Methods: A multidisciplinary meeting of the \u201cChordoma Global Consensus Group\u201d was held in Milan in 2017, focusing on challenges in defining and achieving optimal margins in chordoma with respect to surgery, definitive particle radiation therapy (RT) and medical therapies. This review aims to report on the outcome of the consensus meeting and to provide a summary of the most recent evidence in this field. Possible new ways forward, including on-going international clinical studies, are discussed. Results: En-bloc tumor-sacrum resection is the cornerstone of treatment of primary sacral chordoma, aiming to achieve negative microscopic margins. Radical definitive particle therapy seems to offer a similar outcome compared to surgery, although confirmation in comparative trials is lacking; besides there is still a certain degree of technical variability across institutions, corresponding to different fields of treatment and different tumor coverage. To address some of these questions, a prospective, randomized international study comparing surgery versus definitive high-dose RT is ongoing. Available data do not support the routine use of any medical therapy as (neo)adjuvant/cytoreductive treatment. Conclusion: Given the significant influence of margins status on local control in patients with primary localized sacral chordoma, the clear definition of adequate margins and a standard local approach across institutions for both surgery and particle RT is vital for improving the management of these patients

The sacral chordoma margin

Objective Aim of the manuscript is to discuss how to improve margins in sacral chordoma. Background Chordoma is a rare neoplasm, arising in half cases from the sacrum, with reported local failure in >50% after surgery. Methods A multidisciplinary meeting of the “Chordoma Global Consensus Group” was held in Milan in 2017, focusing on challenges in defining and achieving optimal margins in chordoma with respect to surgery, definitive particle radiation therapy (RT) and medical therapies. This review aims to report on the outcome of the consensus meeting and to provide a summary of the most recent evidence in this field. Possible new ways forward, including on-going international clinical studies, are discussed. Results En-bloc tumor-sacrum resection is the cornerstone of treatment of primary sacral chordoma, aiming to achieve negative microscopic margins. Radical definitive particle therapy seems to offer a similar outcome compared to surgery, although confirmation in comparative trials is lacking; besides there is still a certain degree of technical variability across institutions, corresponding to different fields of treatment and different tumor coverage. To address some of these questions, a prospective, randomized international study comparing surgery versus definitive high-dose RT is ongoing. Available data do not support the routine use of any medical therapy as (neo)adjuvant/cytoreductive treatment. Conclusion Given the significant influence of margins status on local control in patients with primary localized sacral chordoma, the clear definition of adequate margins and a standard local approach across institutions for both surgery and particle RT is vital for improving the management of these patients